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Year : 2005  |  Volume : 39  |  Issue : 4  |  Page : 206-211
Complications of resection and reconstruction in giant cell tumour of distal end of radius - An analysis


Department of Orthopaedics, Institute of Medical Sciences, B.H.U., Varanasi, India

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   Abstract 

Background: The bulk of literature on the subject focuses on the resection of the tumor followed by reconstruction using autologous fibula, however, papers analyzing the failures of this procedure are scanty. The aim is to analyze the various factors responsible for the failures.
Methods: Study included 42 patients of aggressive GCT of distal radius, resected and reconstructed using nonvascularised autologous fibula. Host graft junction was fixed using screws (6), intramedullary nail (21) and plate (15). The minimum follow-up was 2 years or till a complication occurred requiring second surgery.
Result: The major complications were recurrence in 6 cases (spillage of tumor tissue in 3, poor biopsy site 2, recurrence along the nail tract one case); failure of host graft union in 8 cases due to inadequate contact at host graft junction, poor implant selection, inadequate immobilization and infection; significant instability at wrist in 6 cases due to poor stabilization at carpo fibular junction in addition to inherent instability due to poor congruity between fibulocarpal articulations.
Conclusion: Reconstruction of distal end of radius using auto fibula has much higher complication rates than usually believed. A meticulous planning and its execution is must to minimize the problems. Use of dynamic plate for host graft junction and fixation of fibular head to adjacent ulna/carpal bones improves the results.

Keywords: Giant cell tumour; Reconstructive procedure; Fibular graft; Distal Radius

How to cite this article:
Saraf S K, Goel S C. Complications of resection and reconstruction in giant cell tumour of distal end of radius - An analysis. Indian J Orthop 2005;39:206-11

How to cite this URL:
Saraf S K, Goel S C. Complications of resection and reconstruction in giant cell tumour of distal end of radius - An analysis. Indian J Orthop [serial online] 2005 [cited 2019 Sep 20];39:206-11. Available from: http://www.ijoonline.com/text.asp?2005/39/4/206/36570

   Introduction Top


Tumors occurring at the distal end of the radius especially aggressive ones have baffled surgeons from time to time. The question that plagues surgeons is how to effect a complete ablation of the tumour and preserve a functional extremity at the same time.

Myriad of treatment modalities have been used in the past to treat these tumours viz. curettage and bone grafting [1] , curettage and cryotherapy [2] , curettage and cement packing [3] , resection of the tumour and replacement with autografts [4], allografts [5] or prosthesis [6] , resection arthrodesis [7] ulnar translocation [8] and vascularised autologous bone grafts [9] . A surgeon who is confronted with a tumour of the distal end of the radius is confounded by these different modalities and is often at a loss to decide which modality would suit his patient best. Bulk of the literature available focuses on the complete and wide resection of the tumour and its reconstruction by autologous upper end of fibula to treat such cases [10],[11] . Walther [12] in 1911 was the first to describe the use of a free nonvascular proximal fibular graft to replace the resected distal radius. Since most of the cells of non vascularised bone graft die and the 'dead' bone is gradually replaced by living bone, it requires prolonged immobilization and is marred by the complications of delayed union, non union, graft resorption, loss of function, stress fracture, deformity and failure of internal fixation. The various authors have reported various success rates with this procedure [10],[12],[13],[14],[15]

Resection of the tumour and reconstruction of the distal radius by ulnar translocation without complete detachment from surrounding soft tissues was first described by Seradge [8] in 1982. Even this method has its own disadvantages; mainly the loss of movements at wrist and weak grip strength. It is apparent from the preceding account that the treatment of tumour of the distal radius is still a matter of debate; however, considering the good results reported in previous small series, we selected the method of resection and reconstruction arthoplasty by autologous fibula in all our cases. In subsequent follow up the complications prompted us to analyze the pros and cons of this treatment modality with respect to oncological disease control and preservation of function.


   Materials and methods Top


The study sample consisted of patients who were operated in our hospital for aggressive giant cell tumor as defined by Campanacci [16] of the distal end of radius by resection of tumor and reconstruction of gap by autologous fibula transplant. Patients with incomplete records or those not available for follow-up evaluation were excluded from the study. The study included retrospective as well as prospective cases operated from 1986 to 2003. The medical records and plain roentgenographs were carefully studied. Records of histological grading were not available in most of the cases and were not considered for the correlation.

In all the cases, a biopsy specimen was obtained prior to definitive surgery using the Patiala core biopsy needle or open biopsy and evaluated by histopathologist. The bone resected at time of definitive ablative surgery was also sent for histopathological evaluation.

Operative Technique : Under general anaesthesia and pneumatic tourniquet control, a posterolateral incision was made. The superficial branch of the radial nerve was identifie and protected whenever possible. The radius was approached through the space between the brachioradialis and the extensor carpi radialis longus. The radius was skeletonized well above the tumour. The whole distal portion of the radius with the tumor was removed. The upper third of the fibula was exposed and resected; the length being about 1 cm. longer than that of the resected portion of the radius. It was then put into the place previously occupied by the radius and fixed to the proximal fragment of the radius. The fixation technique used depended upon the surgeon and the time period when the surgery was performed. It varied from intramedullary nailing to dynamic compression plating or even single or multiple cortical screws. K wire or cortical screw between fibular head and ulna was used for further stability in last 12 cases in addition a K wire was passed between fibular head and carpal bones. A posterior long arm plaster splint was given after closing the wound in layers over a suction drain.

The period of immobilization and graded exercise programme were guided by the post operative clinical and radiological status. The patients were called for follow up every 3 months for first year and subsequently every 6 months. The clinical observations were made regarding pain, instability, recurrence of tumour, functional status and hand grip strength. Radiological criteria of assessment were status of union at host graft junction, status of graft resorption, stability at fibulo carpal junction, deformity and recurrence.

The patient's ability to carry on with his activities of daily living (ADL) was classified into good, fair and poor as per the following criteria:

Good: These patients had only minimal wrist pain or instability and were able to carry on with most of their routine work without much difficulty e.g. a female who was able to do all her household chores like washing clothes and cooking were rated good.

Fair: The patients had difficulty in carrying on with their routine work due to pain or instability of the wrist but were able to manage most of the their daily activities although with some difficulty.

Poor: These patients had a persistently painful or a grossly unstable wrist (due to post- operative subluxation or recurrence) and were unable to use their operated extremity effectively.

These criteria are subjective and take into account the patient's satisfaction with the outcome of the surgery.

Handgrip strength was measured using a grip strength­measuring device with a spring action; the strength was graded into good, fair or poor as per the following criteria.

a. Good : Patient was able to compress the device by more than half.

b. Fair : Patient was able to compress the device by more than one third but less than one-half.

c. Poor : Patient was unable to compress the device even by one third.


   Results Top


In all, 42 patients (18 females and 24 males) formed the study group. The age at the time of presentation of the patients showed a wide variation from 18 to 55 years. The average age at presentation was 27.4 years. The duration between onset of symptoms and presentation ranged from three month to one and half years, the average duration being six months. The average duration between presentation and surgery was four weeks. The clinical presentations in all the cases were rather uniform. All presented with swelling of variable size, pain and loss of function depending upon the involvement. Pathological fracture was observed in eight patients. Six of the patients included in the present series were treated initially by curettage and autologous cancellous bone grafts, presented with the radiological resorption of the graft.

The duration of postoperative immobilization ranged between 6 weeks to 14 months. The patient's follow up ranged between 24 months to a maximum of 7 years or till they developed the complications requiring another surgical intervention. None of the patient showed pulmonary metastasis at the time of presentation or in subsequent follow up.

Wrist pain: Mild discomfort was noticed in all the successfully united cases whereas the severity of pain was adjudged moderate in all others.

Deep infection: Two cases developed deep infection. It was possible to control the infection in one case still the host graft junction did not unite, whereas in another the plate and screws and the fibula necessitated to be removed due to uncontrolled infection and resorption of the graft. The centralization of ulna was done in this case at later date.

Stability of wrist: There was significant subluxation of carpals over the distal end of transplanted fibula in 6 patients resulting in significant pain, deformity and loss of function [Figure - 1]. In majority subluxation occurred between 3 month to nine months after the surgery. The subluxation was seen in one case of screw fixation group, three cases of intramedullary nail fixation group and in two patients of plate fixation at host graft junction. In four cases, the procedure was changed to centralization of ulna whereas one refused the further surgery. In one case subluxation was association with recurrence of lumunr.Ampulation was done in this case. In another 14 cases, mild to moderate subluxation was observed radiologically but it did not affect the function significantly. In one patient a diastases between fibular head and distal ulna was noticed. In all the 6 cases the wire used for fixing the fibulo carpal or distal fibulo ulnar articulation extruded out prematurely due to loosening within 8 weeks.

Non union at host graft junction / Resorption of graft: The fixation technique used in our earlier cases was step cut and screw fixation (6 cases). Non union and resorption at host graft site occurred in three [Figure - 2] and all were changed to centralization of ulna. In another 21 cases, the host graft junction was fixed with intra medullary nail, of which there was failure of union in four [Figure - 3]. In all these four cases procedure was changed to centralization of ulna. In yet another five cases, where progress of union was not satisfactory, auto cancellous bone grafting helped in achieving union. In one case follow up till union was not possible due to recurrence as the limb was amputated. In the plate fixation group (15), ten showed good union at host graft junction, whereas in one case union did not occur due to deep infection and resorption of graft. Centralization of ulna was done in this case. In two of the cases follow up till union could not be completed due to severe subluxation. The procedure was changed to centralization of ulna in both and in another two the limb was amputated due to recurrence.

Recurrence of tumour: In six cases there was recurrence of tumor observed between 5 months and 14 months [Figure - 4]. In three, there was definitive evidence of contamination by spillage of the tumor tissue. In two the biopsy sire was not included along with the excision of the tumor. In one case recurrence was noticed in the hand around the intramedullary nail [Figure - 5]. Of these six cases, amputation was done in four and local excision of recurred tumor in two. There was second recurrence in one case and he refused to undergo any further surgery.

Hand grip strength: This could be tested only in 25 cases as in others there was either recurrence necessitating amputation or failure of implant, nonunion, resorption of graft, infection or gross instability at wrist. The results were adjudged as good in 12, fair in 10 and poor in 3 in those who showed satisfactory to good results at the end of follow up.

Activities of daily living: this was purely a subjective observation and considered as good in 16, fair in 5 and poor in another four at final analysis.

We observed that of the 42 cases included in this study, uneventful recovery as expected and desired took place only in 25 cases [Figure - 6]. A second surgery was required in 23 cases that included centralization of ulna in 12, amputation in 4 and local excision of recurred tumor in two, bone grafting at host graft junction in 5 cases.


   Discussion Top


The ideal treatment for a tumor of the distal radius has been a topic of consternation for hand and wrist surgeons the world over. Many different modalities of treatment have been used over the years, each with its own pros and cons. In developing countries unfortunately when these lesions are small and amenable to curettage and bone grafting, they are frequently asymptomatic; therefore many such patients come for advice after the tumor has attained a large size destroying the cortex significantly.

The basic aims of treatment while approaching these difficult tumours are a) oncological disease control i.e. a total, effective and lasting removal of all tumour tissue from the forearm that should preclude any subsequent recurrence of the disease in the forearm. b) Minimal residual functional deficit. On the basis of the law of averages, one can postulate that in about 50% of the cases the disease would involve the dominant upper limb. Thus preservation or reconstruction of the normal anatomy to enable retention of as much function in the extremity as possible is a major consideration in the treatment of these tumours. If this basic tenet is ignored, the patient will land up with more disability after operation than the tumour was causing him.

We must remember that wide resection of tumour from the forearm would result in considerable disturbance of the anatomy, obviously producing a gross functional deficit. Reconstructive procedures can replenish this loss only to a certain extent; hence attempts at preserving more functions would be fraught with the dreadful risk of a recurrence. On the other hand loss of a function any more than absolutely necessary is not desirable. It is not difficult to visualize that these two aims are at best conflicting in nature. The ideal procedure should be one that strikes a balance between these two conflicting aims of treatment. The incidence of recurrence after excision of distal radius has been reported between 0­ 50% [10],[14],[15] . Our rate of recurrence (14.3%) is comparable with that in various other series reported in the literature. It appears that recurrences are more due to technical errors during surgery like non inclusion of biopsy site in excision, spillage of tumour in the surrounding tissues or not reaching upto the distal end of tumour and leaving behind part of the tumour etc than the criteria of grading alone. In one interesting case, tumour tissue migrated along with the intramedullary nail into the hand and recurrence was observed there within a year. In the recurred cases correlation with histological grading was not possible due to non availability of data.

Most surgeons today would agree that distal radial tumours are best treated by wide excision; however, this creates a problem of replacement of the excised segment. In the absence of allograft, the wide resection and replacement with autologous fibular graft would seem to be the answer. [10],[11],[15] However, in the present series a number of complications have casted a shadow of doubt on the firmness of this statement. The most frequently seen complication was fibulocarpal subluxation. As many as six patients landed up with subluxed wrist with consequent loss of function and disability and in another 14, subluxation was noticed though not so significant. Various reasons have been cited for this inherent instability of iatrogenically created fibulo carpal joint. Others claim that repair of the ligaments of the wrist and the erstwhile inferior radioulnar joint would prevent such subluxation. Since it is desirable to preserve the fibular articular cartilage, the incongruity of the fibulocarpal joint can not be altered. The repair of ligaments, however, is controversial. Suturing of the inferior radioulnar and radiocarpal ligaments to the transplanted fibula to preserve inherent stability of the wrist joint have also been considered. This, however, presumes that the ligaments must be dissected off the diseased radius and preserved. Others do not consider it wise to leave behind these ligaments in aggressive GCT as it would be against the basic tenet of wide resection. The treating surgeon is once again confronted by the choice between a stable wrist and a wide resection. As an unstable wrist is very disabling and at times severely painful, it may be argued that ligament reconstruction to preserve stability is justified. However, the spectre of a recurrence looms large over this argument. In our series no attempt to reconstruct the ligaments was made. Since all our patients with subluxed wrists had extreme functional disability and except one, none of them had a recurrence, it appears that an attempt to retain the ligaments and repair them to enhance the stability would be justified but not if it increases any chance of recurrence.

Nonunion at host graft junction was another common complication in the present series. It has been pointed out that placing a non-vascularized fibular graft in the forearm amounts to placing an avascular, piece of bone in a relatively avascular area. Revascularisation requires prolonged immobilization of the extremity. If revascularisation fails to occur, the graft behaves like a dead bone and fails to unite with the host. This problem has been tackled by performing a microvascular anastomosis between the feeding vessel of the fibular graft and the radial or anterior interosseous artery[9] . This procedure has been reported to speed up the healing at the host graft junction thereby reducing the period of immobilization required. In addition to being technically demanding and time consuming, this procedure sacrifices two major vessels- the peroneal and the anterior interosseous or radial [17] .

Another interesting point of discussion that arose on analysis was what implant should be used to fix the fibular graft to the radial stump. In the present series intramedullary nail was used for fixation in 21 patients, whereas in another fifteen, a 3.5 mm dynamic compression plate was used for fixation. We also have in our records six cases done at the initial stages where step cut was fixed with screws, however, three among these failed to unite at host graft junction. The high incident of non-union at graft- host junction may have had a contributory component from the lack of compression at the junction site. Such compression can not be achieved by intramedullary implants as evident by failure of union at host graft junction in four cases. A dynamic compression plate, on the other hand, reportedly enhances union by providing compression. Another useful technique to enhance union is step cutting of the radial stump and the fibular graft. It appears presently that step cutting procedures combined with dynamic compression plating would provide the best setting to ensure a union at the graft host junction.

The patients in the intramedullary group and screw fixation group had to be immobilized for relatively longer duration as compared to the group fixed with plate. Although this longer duration of immobilization was desirable to ensure proper revascularization of the graft and its healing to radial stump, it resulted in stiffness of the wrist and consequently a decrease in the hand grip strength. Thus attempts to ensure proper healing of the graft result in decreased function ability.

It is apparent that although good disease control could be achieved in the present series by wide resection of the tumour and reconstruction with a non vascularised fibular autograft, the end results with respect to retention of function in the extremity have been rather poor. The reports in the available literature regarding wide resection of the tumour and replacement by a fibular autograft have been rather more favourable as compared to our result [14],[18],[19]. Twenty three patients were operated for complications. The incidence of repeat surgery in this group was much higher than reported in the other series.

Use of a dynamic compression plate for fixation uniformly, step cutting the radial stump and adjacent fibular surface, use of stabilizing K wires across the newly formed wrist joint and ligament reconstruction are modifications that can alter the nature of our results to better one. The gold standard, however, remains a vascularised fibular graft, which unfortunately, we have no experience with.


   Acknowledgement Top


Authors gratefully acknowledge Prof. S.M. Tuli, Late Prof. TP Srivastava, Late Prof. SV Sharma, Dr. GN Khare, Dr. Amit Rastogi and Dr. S.K. Singh for inclusion of their cases and helping in preparation of this manuscript.

 
   References Top

1.Goldenberg RR, Campbell CJ, Bonfiglio M. Giant cell tumor of bone. An analysis of two hundred and eighteen cases. J Bone Joint Surg (Am). 1970 ; 52: 619 - 664  Back to cited text no. 1    
2. Marcove RC, Weis LD, Vaghaiwalla MR et.al. Cryosurgery in the treatment of giant cell tumor of bone - a report of 52 consecutive cases. Cancer. 1978 ; 41: 957-969  Back to cited text no. 2    
3. Persson BM, Wauter HW. Curettage and acrylic bone cementing in surgery of giant cell tumour of bone. Clin Orthop. 1976 ; 120: 125-133  Back to cited text no. 3    
4. Rao PT. Management of giant cell tumour of bone. Kini Memorial ora­tion. Ind J Orthop. 1993; 27 :96-100  Back to cited text no. 4    
5. Smith RJ, Mankin HJ. Allograft replacement of distal radius for giant cell tumour of distal radius. J Bone Joint Surg (Am). 1977 ; 59: 299-309  Back to cited text no. 5    
6. Gold AM. Use of prosthesis for the distal portion of the radius following resection of a recurrent giant cell tumor. J Bone Joint Surg (Am). 1957; 39: 1374-1380  Back to cited text no. 6    
7. Vander Griend RA, Funderburk CH. The treatment of Giant cell tumor of the distal part of the radius. J Bone Joint Surg (Am).1993; 75: 899-908  Back to cited text no. 7    
8. Seradge H. Distal ulnar translocation is the treatment of giant cell tumor of the distal radius. J Bone Joint Surg (Am). 1982; 64: 67-73  Back to cited text no. 8    
9. Pho RWH. Malignant giant cell tumor of the distal end of the radius treated by a free vascularized fibular transplant J Bone Joint Surg (Am). 1981; 63: 877-884  Back to cited text no. 9    
10. Chiang IM, Chen TH, Shin LY, Lo WH. Nonvascularized proximal fibular autograft to treat giant cell tumour of the distal radius. Zhonghua Yi Xue Za Zhi. 1995 ; 56: 331-317  Back to cited text no. 10    
11. Deb HK, Das NK. Resection and reconstructive surgery in giant cell tumor of bone. Ind J Orthop. 1992; 26 : 13-16  Back to cited text no. 11    
12. Walther M. Resection de extremite inferieure du radius pour osteosa­rcoma Geffe de I extremite superiuete du perone .Sac Chir Par Bull Mem. 1911; 37: 739-747  Back to cited text no. 12    
13. Goni V, Gill SS, Dhillon MS, Nagi ON. Reconstruction of massive skeletal defects after tumour resection. Ind J Orthop. 1992 ; 26 : 13-16  Back to cited text no. 13    
14. Aithal VK, Bhaskaranand K. Reconstruction of the distal radius by fibula following excision of giant cell tumour. Int Orthop. 2003 ; 27: 110­113  Back to cited text no. 14    
15. Harris WR, Lehmann ECH. Recurrent giant cell tumor after en bloc excision of the distal radius and fibular autograft replacement. J Bone Joint Surg (Br). 1983 ; 65: 618-620  Back to cited text no. 15    
16. Campanacci M, Baldini N, Boriani S, Sudanese A. Giant cell tumor of bone. J Bone Joint Surg (Am). 1987; 69: 106-114.  Back to cited text no. 16    
17. Lalla RN, Bhupati SC: Treatment of giant cell tumor of the distal radius by ulnar translocation. Orthopaedics. 1987 ; 10: 735-739.  Back to cited text no. 17    
18. Agrawal AC, Raza HKT, Chandra S. Management of locally aggres­sive Giant cell tumors of the distal radius by excision and reconstruction by ipsilateral autogenous proximal fibular arthroplasty. Ortho J MP Chap­ter. 2002 ; 11: 45-47.  Back to cited text no. 18    
19. Lackman RD, McDonald DJ, Beckenbaugh RD, Sim FH. Fibular reconstruction for giant cell tumour of the distal radius. Clin Orthop. 1987; 218: 232-238  Back to cited text no. 19    

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Correspondence Address:
S K Saraf
Professor of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.36570

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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]

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